Ob-Gyn Coding Alert

1. You should report 99205 (Office or other outpatient visit physicians typically spend 60 minutes face-to-face with the patient and/or family) for the comprehensive initial outpatient problem visit (60 minutes in length) and link it to 626.0 for amenorrhea. Remember that the diagnosis of secondary amenorrhea is the absence of menstruation for at least three months. If the patient missed only one or two periods, you would link 626.8 (Other disorders of menstruation ...) to the service instead.

Because the physician spent a total of 100 minutes with the patient and her mother, you can bill for any additional time that the ob-gyn did not spend performing the history, exam and medical decision-making. In this case, we will assume that the physician spent 60 minutes (the typical time listed for 99205) dealing with the elements of the E/M service. This means the physician can bill for 40 minutes of prolonged services time using code +99354 (Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service; first hour).

Note: You should use prolonged services codes (99354-99357) to bill protracted services related to the outpatient problem visit, but you should not use them for prolonged preventive visits, which instead require modifier -22 (Unusual procedural services). You should report 99354-99357 only with E/M codes that have a time component, such as 99205. Do not use these codes with preventive medicine services codes (99381-99397), which by definition do not have a time component.

2. The code you report for the follow-up visit will be determined by the time the physician spends counseling the patient. In this situation, if the physician spent 25 minutes face-to-face with the patient, report 99214 (detailed established outpatient visit). If the physician spent 15 minutes of face-to-face time, report 99213 (expanded problem-focused outpatient visit).

Because time is the controlling factor for the follow-up visit, it may not meet the level of examination described for the E/M code. Physicians must document the time spent and discussions held.

Report the appropriate diagnosis code, such as V25.09 (contraception, family planning). But check with payers about birth-control coverage, because many insurers do not reimburse for this service.

3. In this case, you would report 622.1 for cervical dysplasia and 99215 for the comprehensive visit.

As in the second scenario described above, time becomes the controlling factor in choosing the appropriate E/M code when counseling or coordination of care constitutes more than 50 percent of the face-to-face time. If time were not the prevailing component (less than 50 percent of the physician time), then 99215 (comprehensive visit) would be appropriate only if the physician's services met two out of three of the following criteria: comprehensive history, comprehensive examination, and high-complexity medical decision-making.

The typical time listed for 99215 is 40 minutes. Because this encounter took 45 minutes and all counseling and coordination of care was face-to-face, you should choose the E/M level based on time: 99215. Document the time spent counseling and the content of the discussion.

4. You should use 57455 (Colposcopy of the cervix including upper/adjacent vagina; with biopsy[s] of the cervix) and link it to 622.1 (Cervical dysplasia). In addition, report 9921x appended with modifier -25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to indicate that the physician performed a separate exam for the breast lump. Link the E/M code (9921x) with 611.72 (Breast lump or mass).

Note: To avoid coding errors, providers should document the colposcopy procedure and breast mass exam separately. For example, the ob-gyn could follow the colposcopy note with a problem-focused return patient visit form documenting the breast history, physical, analysis and treatment plan.